MEDICAL FORM

Please Print - One sheet may be used for multiple guests if there are
no medical conditions
Grade should be grade for the 2012-2013school year.
Child(rens) Name ____________________________ Birthdate ___________
Grade ________
Name ______________________________________ Birthdate ___________
Grade ________
Name ______________________________________ Birthdate ___________
Grade ________
Name of Parent/ Guardian
_______________________________________________________
Address
______________________________________________________________________
City _________________________________________ State __________
Zip _____________
E Mail: ________________________________________________
(Parent or child - most used)
Phone: day
evening
cell 1
cell 2

____________________________
________________________________
_________________________________
__________________________________

EMERGENCY CONTACT (if parent/guardian cannot be reached)

Name ________________________________________
Relationship _________________
Phone day ____________________
evening ________________
cell __________________
HEALTH INSURANCE (please include a copy, front and back, of
your insurance card)
Health Insurance Company
_____________________________________________________
Name of Insured ________________________________
Subscriber #: _______________ Group #: ____________
Insurance Phone #: _____________

HEALTH HISTORY
Does your child(ren) suer or has your child(ren) suered from any of
the following:
Asthma
Diabetes
Seizures
Ear Infections/Swimmers Ear
Eczema
Bee Sting Allergy
Food Allergy (list on back)
Drug Allergy (list on back)
List any and all medications (including dosage) your child will be
required to take while at the Convent. Please label all medications with
childs name. Prescription medications should be in the original labeled
bottle.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
If your child(ren) has any other medical problem please include
details on the back.
Should my child(ren) require minor medical treatment (for headache,
scrapes, coughs, burns, etc.), I give
permission to the nursing sta to administer over-the-counter medicine
and/or herbal products.
Signature of Parent/Guardian: _____________________________________
Date: ___________